Event Notification Report for August 28, 2008

AGREEMENT STATE REPORT - LOST TROXLER MOISTURE DENSITY GAUGE

"On the afternoon of August 28, 2008 at approximately 4:10 pm, the [Alabama Department of Public Health (ADPH)] received a call [from the] RSO for Birmingham Engineering and Construction Company (BECC). [The RSO] advised [ADPH] that one of his technicians had lost a Troxler model 3440 (serial number 17775) containing Cs-137 and Am-241/Be radioactive sources somewhere in the Birmingham area.

"As described by [the RSO], the technician placed the gauge on the back of his pickup without properly securing it in the transport container. After completing his paperwork, he then proceeded to drive back to the office forgetting that the device had not been properly secured. Upon return to the office, the technician realized the mistake. Information made available to the writer indicates that the gauge was discovered missing at approximately 2:00 pm. At that time, [the RSO] was notified and personnel from BECC immediately conducted a search of the job site and route taken by the technician. The route started from the job site at the Grants Mill Road exit on I-459 traveling southbound to I-65 northbound to Lakeshore Drive where the licensee's office is located. The tailgate to the truck was not closed, the device was not in the transport container but the gauge shutter was closed and locked. [The RSO] further indicated that he had called the State Troopers and they indicated that no gauge had been reported found. [The RSO] indicated that he had not yet called city police.

"The writer then contacted [ADPH] and advised them of the incident. Through conversations, it was determined that BECC needed to contact the police and put out a press release, Also, it was determined that the local EMA Director needed to be advised of the incident. [ADPH] committed to calling the RSO back and relaying this information, [an ADPH representative] also indicated that he would notify the Jefferson County Director.

"The writer had no additional conversation with licensee personnel."

* * * UPDATE FROM STATE OF ALABAMA (VIA E-MAIL) TO KLCO ON 9/02/08 AT 1027 EDT * * *

"On Friday 29 August 2008 Alabama reported that a Troxler Model 3440 device had been lost from a pickup truck the afternoon before in Birmingham, Alabama.

"On Sunday afternoon 31 August 2008 an individual reported to the Irondale, Alabama (part of greater Birmingham) Police Dept that they had found the device and wished to claim the reward. The device is now in the possession of the licensee, BECC, Inc. It was apparently undamaged save for a few scratches. The licensee did a leak test on the device and is awaiting results from lab.

"The State of Alabama is awaiting the licensee's 30 day report and corrective actions. A decision on enforcement actions will be made after review of the licensee's response."

Notified R1DO (Dwyer), FSME EO (Burgess) and ILTAB (via e-mail)

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

UNUSUAL EVENT - INTERNAL FLOODING IN SERVICE WATER INTAKE STRUCTURE

"Licensee entered into Unusual Event due to EAL 9.7.1, which is internal flooding in excess of sump handling capability affecting safety related areas of the plant.

"Failure of the sump pump level switches in the active Service Water Intake Structure (SWIS) bay resulted in several inches of water on the floor and receipt of a SWIS 'Pump Room Flooded' alarm. There was no excessive leakage from the service water system and no damage to safety related systems in the room. Sump pumps are now operating and level in the SWIS bay is lowering.

"All safety related systems are operable except for the 'A' Diesel Area Panel Room Supply Fan, which is cleared and tagged for scheduled maintenance."

Licensee will notify the NRC Resident Inspector and has notified the states of New Jersey and Delaware and the local township.

* * * UPDATE PROVIDED AT 0746 EDT ON 08/28/08 FROM DAN KLINGER TO JEFF ROTTON * * *

At 0736 EDT the licensee terminated the Unusual Event. The SWIS sump pumps are working as designed using the sump pump level switch. The sump pumps are running and lowering level (approximately 0.75 inches remains on the SWIS floor).

The licensee has notified the State of New Jersey and Delaware Emergency Response organizations and will be notifying the NRC Resident Inspector.

Notified R1DO (Powell), NRR EO (Thorp), IRD MOC (McDermott), DHS (McKentry), and FEMA (Sweetser).

OFFSITE NOTIFICATION DUE TO SMALL OIL SPILL INTO INTAKE BAY

During a diver inspection of 0A SX [Essential Service Water] Makeup pump intake structure, hydraulic oil was spilled into the intake bay. The oil was Envirologic 146, a natural ester based hydraulic oil. It is believed a total of approximately 2 gallons of oil leaked from the pump into the intake bay. Approximately 6 inch - 12 inch oil sheen was seen on the Rock River. Oil booms used to capture spilled oil. Oil spill was contained at 0710 CDT. Licensee notified the National Response Center, Illinois Emergency Management Agency, and Ogle county Emergency Services Disaster Agency.

The licensee notified the NRC Resident Inspector.

National Response Center Report #: 882049

REPLACEMENT DIAPHRAGM FAILURES DUE INADEQUATE CURE AND OPERATION OVER MAXIMUM PRESSURE

"Fisher was recently notified by Luminant, Comanche Peak SES of two replacement diaphragm failures. These diaphragms had been in service for approximately 3.1 years.

"The diaphragms lost frictional flange retention in a progressive type failure which transferred retention stress to the bolt/diaphragm interfaces and caused localized stresses great enough to initiate rupture. Rupture propagation occurred catastrophically in multiple directions and rapid loss of actuator pressure resulted and consequently, opening of the valve."

This is applicable to all Fisher size 80, type 657 and 657NS sliding stem valve actuators sold to the nuclear industry by Fisher Controls International LLC that are equipped with nitrile/nylon diaphragms (Fisher part number 1R6375X0072). It is unknown what plants in addition to Comanche Peak are affected by this report.

UNUSUAL EVENT DECLARED DUE TO LOSS OF COMMUNICATIONS WITH OFFSITE AGENCIES

At 1348 EST the licensee declared an Unusual Event and entered EAL 7.3.2 due to the loss of the ability to communicate with offsite organizations. The loss of communications was due to a maintenance worker opening the wrong breaker. This caused the loss of all land based phone lines in the control room, the satellite phones and ERDS. The power was restored and the EAL was exited at 1414.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM DAN DEAN TO PETE SNYDER AT 1930 ON 8/28/08 * * *

"Ginna Station is updating the Unusual Event classification and declaration made at 1348 hours on August 28th, 2008. Information received following termination of the event at 1414 hours, shows that two telephones were available in the Control Room during the entire event. At the time of the classification, the Shift Manager did not have this information."

The licensee notified the NRC Resident Inspector.

CONTAMINATION EVENT DUE TO BROKEN TC-99m VIAL

The licensee was incubating six vials of Tc-99m (Cardiolite brand 1500 millicuries each) in the iodine room. At the end of the incubation period the technician removed the first five vials without incident. The sixth vial was attempted to be removed. When the tongs touched the vial the technician heard a sound that indicated that the vial had broken. The technician called the pharmacist over to verify the break.

A cleanup was initiated. The pharmacist's lab coat was contaminated, the technician's lab coat, shirt, and dosimeter were contaminated, and an additional technicians' lab coat was contaminated. All contaminated items were removed and stored.

The contamination was contained in the iodine room. Removable surface contamination was cleaned up. The RSO did a survey of the personnel and the technician directly involved in the incident had a small amount of contamination on her hands and her hair was reading 10 mr/hr on contact. The RSO instructed the technician to return to home, shower to remove the remaining contamination and bag her clothes and return to work. Upon returning the employee was cleared of contamination, but her clothes were reading above background.

The licensee cleanup strategy for the iodine room is to allow it to decay as the half-life of Tc-99m is 6 hours.

The licensee notified Region 2 (David Collins, Rebecca Nease) and was directed to Region 1 (Powell).

LEAK IN HIGH PRESSURE FIRE WATER SYSTEM

"At 1143, on 8/28/08, the Plant Shift Superintendent was notified of a large water leak on High Pressure Fire Water system (HPFW) A-12 in building C-333 due to a piping rupture. The HPFW system provides water for fire suppression to the plant's process buildings. A-12 is 1 of 66 HPFW systems in this process building. Leak analysis indicates the HPFW system A-12 would not have been able to perform its intended safety function while the leak was occurring. The leak was determined to be between the process building and the post indicating valve (PIV). The PIV for this system was closed which isolated the leak. Required TSR LCO actions have been and are being performed. This is being reported as an event in which equipment is disabled or fails to function as designed when the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and no redundant equipment is available.

"The NRC Senior Resident Inspector has been notified of this event."

* * * UPDATE PROVIDED BY ROD COOK TO JASON KOZAL ON 8/29/08 AT 1611 * * *

"On 8/29/08, the Kentucky Department of Water (KDOW) was notified that approximately 30,000 gallons of recirculating water (RCW) from the HPFW system containing 4 ppm phosphorus residual was discharged through Outfall 9. RCW discharge to Outfall 9 is reportable to KDOW as a bypass of a treatment system that causes an exceedance of a permit limit per 401 KAR 5:065 Section 1(12)(f).

"The NRC Senior Resident Inspector has been notified of this event."

Notified R2DO (Nease) and NMSS EO (Mamish).

MEDICAL EVENT - PRESCRIBED DOSE DIFFERED GREATER THAN 20%

"Male patient was treated Thursday August 28, 2008 with 'TheraSpheres [TS]' (a Y-90 pure beta-emitting Nordion microsphere product for liver cancer treatment). The procedure began at about 1600 hours. The written directive specified a radiation dose to the right liver lobe of 92 Gy. This required the implantation into the right liver lobe of 1.83 GBq of Y-90 at 4 PM.

"Y-90 operations are guided by a written procedural check-list which is read out aloud in the Operating Room in a step-by-step fashion during every operation. Unfortunately, the [authorized user, (AU)] failed to carry out a step which had been read out aloud to him which required that a blue stopcock in the delivery device be turned toward the delivery device's 'waste vial'. Note: When the blue stopcock is turned toward the 'waste vial' the flow is from the 'source vial' to patient. Otherwise, flow is to the 'waste vial.'

"When [the AU] began the 'source vial' flushing sequence, he saw that flow in the delivery device's transparent tubing was going from the 'source vial' to the 'waste vial' (instead of to the patient). He then turned the blue stopcock to the correct position and continued the flushing sequences. Unfortunately, about 2/3 of the initial activity in the 'source vial' had been diverted to the waste vial during the start of the first flushing sequence. The flushing sequences were repeated several times until no further reduction was observed in the delivery device dose-rate indicators (normally, flushing ceases when the two dose-rate meters indicate 0.0 Mr/h). As per procedure, the 'waste vial,' together with contaminated tubing, stopcocks, catheters and gloves were placed in a plexiglass-shielded waste 'mayo' jar and its dose-rate measured at a distance of 30 cm between jar and meter. Note: The Y-90 activity in the waste jar is determined by a ratio calculation involving the dose-rate measured with the source vial within the plexiglass shield located at 30 cm from the survey meter. (Most beta particles are absorbed in the mayo jar and plexiglass shield. Survey meter measures X-rays produced by the ~1 MeV particles, and not the beta particles).

"From the waste container measurements it appears that 0.68 GBq were implanted into the patient's [right (RT)] liver, with 0.12 GBq going to the patient's lungs. The calculated dose to the RT liver is 34.3 Gy and to the lungs it is 13.2 Gy. The dose delivered to the target is low by about 63%. This, then, is a medical event requiring notifications.

"Note: There was no leakage from the delivery device, its tubes, catheters, stopcocks, therefore, there was no contamination to be cleaned up. All other procedural steps were completed as required by our procedures. The OR and the personnel exiting it were checked for contamination and none was found.

"This scenario, of an accidental diversion of activity to the delivery device's waste vial, has occurred at other institutions. This was RSO's motivation, many months ago, to change the print color of this procedural step from black to red, and to alert the AU to this possibility. This event was due to a simple mistake that may be resolved when a newer version of a TS delivery device is introduced by Nordion in the near future."


A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

THREE UNACCOUNTED FOR NICKEL-63 SOURCES

"Two Hewlett Packard (HP) gas chromatographs with three HP Nickel-63 detectors at a source strength of 15 millicuries each were determined to be missing from their stored warehouse (Building #4) at NOAA ESRL laboratory in Boulder, CO by [the licensee] on 29 March 2007. A search was begun with the belief that the sources had been moved or used by someone in the NOAA facility because Building #4 was used as a temporary post office for about one year and [NOAA] boxes may have been moved to other locations on the site. The serial numbers of the missing sources were L1231 and L1941 in an HP model 5890 II GC with serial number 2518A05469, and M2087 in another HP model 5890 II GC with serial number 2518A05471. [NOAA] use[s] the ECDs in a worldwide network to measure atmospheric substances (freons) that destroy stratospheric ozone. The network includes stations at Pt. Barrow, Alaska; Niwot Ridge, Colorado; Mauna Loa, Hawaii; American Samoa, and South Pole, Antarctica. Source serial #s L1231 and L1941 were last wipe tested on 24 July 2001. The GC containing those sources was then retired from service at Niwot Ridge and placed in storage on 20 August 2001. Source serial# M2087 was last wipe tested on 7 February 2000. The GC containing those sources was retired from service from American Samoa and placed in storage. On 9 August 2002, all sources were moved to Building #4 for long term storage. They were not wipe tested further since they were inactive.

"Building #4 is locked 24 hours, seven days a week, and occasionally left opened during working hours without security monitors or staff members in the storage area. The Boulder DoC campus is guarded with access control, but not fenced in. The following activities were investigated to locate the three missing stored sources:

"(1). The Department of Commerce Laboratories in Boulder stores all excess property in Building #4 to make it ready for transport to the Denver Federal Center for posting of availability of excess property to all government agencies. If the excess property was not transferred to another government agency over a year period, then it will be sold to general public. The thought was that the shipper had taken the instruments with their sources by accident to the Denver Federal Center. We contacted the shipper and the Denver Federal Center, and both reported that they were never picked up prior to 2007. The procedure also requires that each piece of excessed property be sealed with plastic on a pallet with paper work attached, so this possibility was ruled out in 2007.

"(2). [The licensee] contacted all current employees in the group to make sure that the sources were not loaned out. Nothing was discovered.

"(3). [The licensee] contacted all past employees in the group to make sure that they had not borrowed the sources without our knowledge. Nothing was discovered.

(4). [The licensee] contacted HP, now Agilent Technologies, to see if anyone reported the instruments with the sealed sources as being serviced. Nothing was discovered.

"(5). [An employee] of ESRL/GMD contacted all observatory staff and inspected all spares parts at our observatories (except American Samoa) over the past year to see if they were there. This required a year for someone from our group to visit each site, including South Pole since it is only opened three months each year. Nothing was discovered.

"(6). [The licensee] contacted LabX, a web site where used laboratory equipment is sold, to see if the instruments with the missing sources were sold on LabX. Nothing was discovered.

"(7). Many members of the NOAA/ESRL/GMD searched the complete DoC site and all rental storage facilities in Boulder were completed on 15 August 2008. Nothing was discovered.

"[The licensee] concluded that these three sources were lost on 28 August 2008 after investigating all of the leads above. The probable outcome is that the sources and their instruments were moved out of NOAA property in Boulder. They are either misplaced or stolen. [The licensee] only contacted one used instrument web site, LabX, a[n] eBay type service, ---they only providing a listing service. In the used instrument market, these instruments are being sold for as high as $12K each. They are the most expensive items that [the NOAA] group currently stores. They are sealed low level beta sources. There is little or no risk to any individuals that worked with them and they do not create a problem for the public at large."


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.